Day: January 21, 2020

      

Episodic/Focused   SOAP Note Exemplar (pls use this template)
 

Focused   SOAP Note for a patient with chest pain

 S.
  CC: Chest pain
 

  HPI: The patient is a 65 year old AA male who developed sudden onset of   chest pain, which began early this morning.  The pain is described as   crushing and is rated nine out of 10 in terms of intensity. The pain is   located in the middle of the chest and is accompanied by shortness of breath.   The patient reports feeling nauseous. The patient tried an antacid with   minimal relief of his symptoms.
 

  PMH: Positive history of GERD and hypertension is controlled
 

  FH: Mother died at 78 of breast cancer; Father at 75 of CVA.  No   history of premature cardiovascular disease in first degree relatives.
 

  SH : Negative for tobacco abuse, currently or previously; consumes   moderate alcohol; married for 39 years
 

  ROS   
General–Negative for fevers,   chills, fatigue
Cardiovascular–Negative for   orthopnea, PND, positive for intermittent lower extremity edema
Gastrointestinal–Positive for   nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary–Positive for   intermittent dyspnea on exertion, negative for cough or   hemoptysis  

 

O.

VS:   BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70

General–Pt appears diaphoretic and anxious

Cardiovascular–PMI is in the 5th inter-costal   space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is   heard best at the

second   right inter-costal space which radiates to the neck.

A   third heard sound is heard at the apex. No fourth heart sound or rub are   heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is   noted.

Gastrointestinal–The abdomen is symmetrical   without distention; bowel

sounds   are normal in quality and intensity in all areas; a

bruit   is heard in the right para-umbilical area. No masses or

splenomegaly   are noted. Positive for mid-epigastric tenderness with deep palpation.

Pulmonary— Lungs are clear to   auscultation and percussion bilaterally 

Diagnostic   results: EKG, CXR, CK-MB (support with evidenced and guidelines)

A.

Differential   Diagnosis:

1)   Myocardial Infarction (provide supportive documentation with evidence based   guidelines).

2)   Angina (provide supportive documentation with evidence based guidelines).

3)   Costochondritis (provide supportive documentation with evidence based   guidelines).

Primary   Diagnosis/Presumptive Diagnosis: Myocardial Infarction

P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

Assignment 1: Case Study Assignment: Assessing Neurological Symptoms

Case #2: 

CASE STUDY 2: Numbness and Pain A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools

Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors.

In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

To Prepare

 You will be assigned to a specific case study for this Case Study Assignment (Please see Above)

Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format( as in exampler above) rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

With regard to the case study you were assigned:

Review this week’s Learning Resources, and consider the insights they provide about the case study.

Consider what history would be necessary to collect from the patient in the case study you were assigned.

Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

 

The Case Study Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided ( ABOVE). Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 

Resource for references

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

• Chapter 7, Mental Status

       This chapter revolves around the mental status evaluation of an      individuals overall cognitive state. The chapter includes a list of      mental abnormalities and their symptoms.

• Chapter 23, Neurologic System

       The authors of this chapter explore the anatomy and physiology of the      neurologic system. The authors also describe neurological examinations and      potential findings.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

• Chapter 2, “The Comprehensive History      and Physical Exam” (“Cranial Nerves and Their Function” and      “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)

This article reviews the use of electrocenographs (EEG) to assist in differential diagnoses. The authors provide differential diagnostic scenarios in which the EEG was useful.

Prepare an 4-5 page paper on the importance of nursing-sensitive quality indicators.

As you begin to prepare this assessment you are encouraged to complete the Conabedian Quality Assessment Framework activity. Quality healthcare delivery requires systematic action. Completion of this will help you succeed with the assessment as you consider how the triad of structure (such as the hospital, clinic, provider qualifications/organizational characteristics) and process (such as the delivery/coordination/education/protocols/practice style or standard of care) may be modified to achieve quality outcomes.

The American Nursing Association (ANA) established the National Database of Nursing Quality Indicators (NDNQI) in 1998 to track and report on quality indicators heavily influenced by nursing action.

NDNQI was established as a standardized approach to evaluating nursing performance in relation to patient outcomes. It provides a database and quality measurement program to track clinical performance and to compare nursing quality measures against other hospital data at the national, regional, and state levels. Nursing-sensitive quality indicators help establish evidence-based practice guidelines in the inpatient and outpatient settings to enhance quality care outcomes and initiate quality improvement educational programs, outreach, and protocol development.

The quality indicators the NDNQI monitors are organized into three categories: structure, process, and outcome. Theorist Avedis Donabedian first identified these categories. Donabedians theory of quality health care focused on the links between quality outcomes and the structures and processes of care (Grove, Gray, Jay, Jay, & Burns, 2015).

Nurses must be knowledgeable about the indicators their workplaces monitor. Some nurses deliver direct patient care that leads to a monitored outcome. Other nurses may be involved in data collection and analysis. In addition, monitoring organizations, including managed care entities, exist to gather data from individual organizations to analyze overall industry quality. All of these roles are important to advance quality and safety outcomes.

The focus of Assessment 4 is on how informatics support monitoring of nursing-sensitive quality indicator data. You will develop an 810 minute audio (or video) training module to orient new nurses in a workplace to a single nursing-sensitive quality indicator critical to the organization. Your recording will address how data are collected and disseminated across the organization along with the nurses role in supporting accurate reporting and high quality results.

Reference

Grove, S. K., Gray, J. R., Jay, G.W., Jay, H. M., & Burns, N. (2015). Understanding nursing research: Building an evidence-based practice (6th ed.). St. Louis, MO: Elsevier.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• Competency 1: Describe nurses and the interdisciplinary teams role in informatics with a focus on electronic health information and patient care technology to support decision making. 
  • Describe the interdisciplinary teams role in collecting and reporting quality indicator data to enhance patient safety, patient care outcomes, and organizational performance reports.
• Competency 3: Evaluate the impact of patient care technologies on desired outcomes. 
  • Explain how a health care organization uses nursing-sensitive quality indicators to enhance patient safety, patient care outcomes, and organizational performance reports.
• Competency 4: Recommend the use of a technology to enhance quality and safety standards for patients. 
  • Justify how a nursing-sensitive quality indicator establishes evidence-based practice guidelines for nurses to follow when using patient care technologies to enhance patient safety, satisfaction, and outcomes.
• Competency 5: Apply professional, scholarly communication to facilitate use of health information and patient care technologies. 
  • Deliver a professional and effective audio tutorial on a selected quality indicator that engages new nurses and motivates them to accurately report quality data in a timely fashion.
  • Follow APA style and formatting guidelines for citations and references.

Preparation

This assessment requires you to prepare a 4-5 page paper on the importance of nursing-sensitive quality indicators. To successfully prepare for your assessment, you will need to complete the following preparatory activities:

• Select a single nursing-sensitive quality indicator that you see as important to a selected type of health care system.
• Conduct independent research on the most current information about the selected nursing-sensitive quality indicator.
• Interview a professional colleague or contact who is familiar with quality monitoring and how technology can help to collect and report quality indicator data. You do not need to submit the transcript of your conversation, but do integrate what you learned from the interview into the audio tutorial. Consider these questions for your interview: 
  • What is your experience with collecting data and entering it into a database?
  • What challenges have you experienced?
  • How does your organization share with the nursing staff and other members of the health care system the quality improvement monitoring results?
  • What role do bedside nurses and other frontline staff have in entering the data? For example, do staff members enter the information into an electronic medical record for extraction? Or do they enter it into another system? How effective is this process

Instructions

For this assessment, imagine you are a member of a Quality Improvement Council at any type of health care system, whether acute, ambulatory, home health, managed care, et cetera. Your Council has identified that newly hired nurses would benefit from comprehensive training on the importance of nursing-sensitive quality indicators. The Council would like the training to address how this information is collected and disseminated across the organization. It would also like the training to describe the role nurses have in accurate reporting and high-quality results.

The Council indicates a recording is preferable to a written fact sheet due to the popularity of audio blogs. In this way, new hires can listen to the tutorial on their own time using their phone or other device.

As a result of this need, you offer to create an audio tutorial orienting new hires to these topics. You know that you will need a script to guide your audio recording. You also plan to incorporate into your script the insights you learned from conducting an interview with an authority on quality monitoring and the use of technology to collect and report quality indicator data.

You determine that you will cover the following topics in your audio tutorial script:

Introduction: Nursing-Sensitive Quality Indicator

• What is the NDNQI?
• What are nursing-sensitive quality indicators?
• Which particular quality indicator did you select to address in your tutorial?
• Why is this quality indicator important to monitor? 
  • Be sure to address the impact of this indicator on quality of care and patient safety.
• Why do new nurses need to be familiar with this particular quality indicator when providing patient care?

Collection and Distribution of Quality Indicator Data

• According to your interview and other resources, how does your organization collect data on this quality indicator?
• How does the organization disseminate aggregate data?
• What role do nurses play in supporting accurate reporting and high-quality results? 
  • As an example, consider the importance of accurately entering data regarding nursing interventions.

Additional Requirements

• References: Cite a minimum of three scholarly and/or authoritative sources.
• APA: Submit along with the recording a separate Reference page that follows APA style and formatting guidelines. For an APA refresher, consult the page on Campus.